Special Report

Problems associated with diabetes care

in India

Vijay Viswanathan*1 & V Narayan Rao1

Practice Points

„„ Developing countries such as India face a huge burden of diabetes and its complications.

„„ Several issues in delivering diabetes care prevail in these countries, including socioeconomic factors and
problems with medical infrastructure.

„„ Appropriate monitoring and follow-up of diabetic patients is routinely not carried out by general
physicians in India.

„„ Proper access to healthcare needs is lacking in several parts of India, in addition to a lack of requisite
medical facilities.

„„ The financial burden of diabetes both on the patient and the nation’s economy is extremely high, which
might hinder efficient care.

„„ Presence of economic disparities owing to major differences in diabetes care delivery in the government
and private sectors is an additional burden.

„„ Nonadherence to recommended guidelines by some of the government institutions results in

inappropriate diabetes care.

„„ Effective strategies and policies to tackle these problems involved in diabetes care are needed to reduce
the prevailing burden of diabetes.

SUMMARY More than 61 million people with diabetes live in India, a country that is
already facing challenges such as malnutrition, poverty and socioeconomic burden caused
by communicable diseases. The main reasons for the ever-increasing diabetes epidemic
are population growth, urbanization, unhealthy food habits, obesity and lack of physical
activity. Diabetes also causes other complications, including cardiovascular disorders,
diabetic retinopathy, diabetic nephropathy and peripheral neuropathy, which are
responsible for severe morbidity and mortality. Treatment of diabetes and its complications
is a major challenge in India owing to several issues, including sociocultural factors, lack
of appropriate facilities for diabetes care, an inadequate health system, poor monitoring
and follow-up of patients, and problems in implementing effective management and

1
MV Hospital for Diabetes & M Viswanathan Diabetes Research Centre, WHO Collaborating Centre for Research, Education & Training in
Diabetes, No 4, West Mada Church Street, Royapuram, Chennai 600 013, Tamil Nadu, India
*Author for correspondence: Tel.: +91 442 595 4913; Fax: +91 442 595 4919; drvijay@mvdiabetes.com part of

10.2217/DMT.12.62 © 2013 Future Medicine Ltd Diabetes Manage. (2013) 3(1), 31–40 ISSN 1758-1907 31
Special Report  Viswanathan & Rao
educational strategies. Healthcare professionals and policymakers have to come together
to address these problems in diabetes care and design appropriate preventative and
management strategies.
Diabetes was previously considered to only
affect more affluent communities and societies.
Developing countries, which are already crip­
pled with infectious diseases such as tubercu­
losis, AIDS and malaria, were considered to be
almost immune from diabetes. Nevertheless,
the situation has been changing in recent years,
and chronic noncommunicable diseases (NCDs)
such as diabetes, hypertension and cardio­
vascular disorders have become the most serious
health concerns in both developed and develop­
ing countries [101] . It has been estimated that the
largest increase in the number of people with
diabetes will occur in the regions comprising the
developing countries [1] .
The main risk factors for the high preva­
lence of diabetes include high familial aggrega­
tion, obesity, insulin resistance and metabolic
syndrome, lifestyle changes such as increased
consumption of saturated fats, sugars and sed­
entary behavior as a result of urbanization, and
gestational diabetes [2] . Moreover, Indians are
more prone to developing diabetes and coro­
nary artery disease, owing to the prevalence of
the so-called ‘Asian-Indian phenotype’, which
consists of increased insulin resistance, higher
waist circumference despite lower BMI, lower
adiponectin and higher high sensitive C-reactive
protein levels [3] .
Unlike in the West, where older populations
are mostly affected, the burden of diabetes in
Asian countries is disproportionately high in
young- to middle-aged adults [4,5] . Furthermore,
diabetes-related complications such as nephrop­
athy are also a huge burden in developing
countries. The WHO Multinational Study of
Vascular Disease in Diabetes showed that pro­
teinuria was associated with an increased risk
of death from chronic kidney disease or cardio­
vascular disease, as well as death of any cause
[6] . Foot-related complications such as chronic
nonhealing ulcers and amputations cause severe
morbidity and mortality [7] .
This ever-increasing epidemic of diabetes
and its complications could have long-lasting
adverse effects on a nation’s health and econ­
omy, especially in a developing country such
as India, which has several socioeconomic and
political barriers in the management of diabetes.
Problems such as lack of proper awareness about
32 Diabetes Manage. (2013) 3(1)
diabetes, lack of better healthcare facilities dedi­
cated towards diabetes care, a poor economy,
nonadherence to treatment and diet advice, and
sociocultural factors are some of the challenges
in diabetes care in India. Tackling these prob­
lems requires a concerted and multidisciplinary
approach from various stakeholders and profes­
sionals involved in diabetes care. Effective pre­
ventive and educational programs/campaigns
have to be implemented by govern­ mental
and/or private organizations to increase the
awareness about the risk factors of diabetes and
its complications.
Global burden of diabetes
The global prevalence of diabetes was reported
to the world when the 5th edition of the
International Diabetes Federation (IDF) Atlas
was released during World Diabetes Day,
14 November 2011 [1] . The number of people
with diabetes was approximately 366 million
in 2011, and by the year 2030 this number has
been predicted to increase to 552 million. It is
also estimated that approximately 80% of peo­
ple with diabetes live in the low- and middle-
income countries, which are designated as the
developing economies in the world. China and
India will bear the major burden of diabetes,
with an estimated 129.7 and 101.2 million cases,
respectively, by 2030. The largest age group cur­
rently affected by diabetes is the 40–59 years age
group, and by 2030 this is expected to move to
the 60–79 years age group [1] . In addition, there
will be a doubling of prevalence of diabetes in
the Middle East, north Africa, south Asia and
sub-Saharan Africa. More than 1 million people
die due to diabetes each year, two-thirds of these
are in developing countries [8] . Undiagnosed dia­
betes accounts for 85% of those with diabetes in
studies from South Africa, 80% in Cameroon,
70% in Ghana and more than 80% in Tanzania
[102] .
Burden in India
In India, as in other low- and middle-income
countries, diabetes and other NCDs are rela­
tively overshadowed by the persistent burden of
communicable and nutrition-related diseases.
While these diseases are still present – although
slowly decreasing – the rise of NCDs has been
future science group

rather fast. According to the World Health
Report 2005 [9] , NCDs already contribute to
52% of the total mortality in India and this is
expected to increase to 69% by the year 2030
[10] . Therefore, countries such as India are cur­
rently facing an epidemiologic transition with a
‘double burden’ of disease. As per the latest IDF
atlas, there were approximately 61.3 million peo­
ple with diabetes in India, which will increase to
more than 100 million by 2030 [1] .
There is a bit of controversy regarding the
prevalence of diabetes in India, since most of
the available data are derived from a few scat­
tered studies conducted in different parts of the
country. Few multicentric studies are available,
those published include: the Indian Council
of Medical Research (ICMR) study conducted
during the 1970s, which reported a prevalence
of 12–19% in urban areas and 4–10% in the
rural areas of India [11,12] ; the National Urban
Diabetes Survey (NUDS), which reported a
prevalence of more than 12% among urban
Indians [13] ; the Prevalence of Diabetes in India
Study (PUDIS) that reported a prevalence of
5.9 and 2.7% among urban and rural subjects,
respectively [14] ; and the WHO-ICMR NCD
Risk Factor Surveillance study, which reported
greater than 11% prevalence of diabetes among
urban Indians [15] . Hence, there has been no
national study that has looked at the prevalence
of diabetes in India as a whole, covering all the
states of the country or even in any single state
with comprehensive urban and rural representa­
tion. Nevertheless, the available data certainly
provide at least some relevant information on
the prevalence of diabetes in India. For exam­
ple, a recent multicentric study reported the
overall prevalence of diabetes to be 10.4% in
Tamil Nadu, 8.4% in Maharashtra, 5.3% in
Jharkhand and 13.6% in Chandigarh, with a
significantly high prevalence rate in the urban
settings compared with the rural areas in these
states [16] . Another study in the Ernakulam
district of Kerala reported 20% prevalence [17] .
Regarding the prevalence of diabetic complica­
tions, there are several clinic-based and a few
population-based studies. Chennai Urban Rural
Epidemiology Study (CURES) and Chennai
Urban Population Study (CUPS) provide pop­
ulation-based data from India on virtually all
complications of diabetes. CURES reported an
overall prevalence of 17.6% diabetic retino­pathy
[18] , 2.2% overt nephropathy and 26.9% micro­
albuminuria [19] . The prevalence of peripheral
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Problems associated with diabetes care in India  Special Report
neuropathy was reported to be 26.1% [20] .
Results from CUPS show that coronary artery
disease was observed in 21.4% of diabetic sub­
jects and peripheral vascular disease in 6.3% of
diabetic subjects [21,22] .
Problems involved in diabetes care
in India
Management of diabetes and its complications
in India is a huge challenge owing to several
problems, including a lack of general awareness
about diabetes and its complications among the
population, and scarcity of healthcare person­
nel, monitoring equipment and even drugs,
especially in remote areas. All of these issues
significantly contribute to delayed presentation
and missed diagnosis, which further increases
the existing burden of diabetes.
Awareness of diabetes in India
„„
Patients’ lack of knowledge about diabetes can
hinder their ability to manage their disease.
Several studies have looked at the awareness
levels of diabetes among both patients and
healthcare providers. CURES reported that
nearly 25% of the population was unaware of
diabetes and only 22.2% of the population and
41% of known diabetic subjects felt that diabetes
could be prevented [23] . The study also reported
that awareness levels increased with education,
although only 42.6%, comprising mainly post­
graduates, medical professionals and lawyers,
knew that diabetes could be preventable. The
knowledge of risk factors of diabetes was even
lower, with only 11.9% of study subjects report­
ing obesity and physical inactivity as the risk fac­
tors; 23% knew that diabetes could lead to foot
problems; and only 5.8% knew it could cause
heart attack [23] . Another population-based
study reported that only 41% of adult Indians
aged over 20 years were aware of the risk of dia­
betes and almost all diabetic patients (92.3%)
sought the help of a general practitioner for treat­
ment instead of a diabetic specialist [24] . Hence,
there is a pressing need to improve the awareness
of diabetes among the general population as well
as diabetic patients in India. This is important as
better patient self-management ability is strongly
related to improved diabetes control.
Diagnosis & access to treatment for
„„
diabetes
One of the foremost aspects of diabetes care and
management is timely diagnosis and adequate
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Special Report  Viswanathan & Rao
treatment, in the absence of which complica­
tions and morbidity due to diabetes can increase
drastically. In India, Type 2 diabetes remains
un­detected for many years and the diagnosis
is often made from associated complications
or incidentally through an abnormal blood or
urine glucose test. This results in more than half
of the diabetes population being undetected [25] .
Diab-Care Asia, a multicountry study in Asia,
reported that diagnosis of diabetes among
Indian subjects was determined at a delayed
stage, with the mean age being 43.6 years, and
that 50% had poor diabetes control, as measured
by HbA1c, and 54% had late severe complica­
tions [26] . In another study, it was observed that
approximately 70% of diabetic patients were
diagnosed by general practitioners and diag­
nostic tests for complications were prescribed
for only a few patients – 17.6% for ophthalmic
examination, 5.6% for kidney function tests and
4.2% for lipid tests [27] .
Another important aspect is the availability of
and access to diabetes drugs. An estimate based
on sales of antidiabetic pharmaceutical agents
showed that, on average, only 10–12% of people
with diabetes received modern pharma­­­­cological
treatment in India [28] . The availability of glib­
enclamide in public health facilities varied from
100 to 3.8% in the states of Karnataka and
West Bengal, respectively [29] . Although insulin
therapy is accepted as one of the most effective
and dependable treatment option, barriers to its
use were identified in the IMPROVE Control
India study [30] . In most patients, insulin was
delayed until it was absolutely necessary or
when the HbA1c levels had deteriorated further
to approximately 9%. Moreover, this study also
observed several other problems in the manage­
ment of diabetes, such as lack of standardization
in laboratory techniques and irregular monitor­
ing of diabetes status [30] . Therefore, problems
such as the uncertainty of availability of diabetic
medicines and lack of pricing control over the
private sector result in poor compliance with
medication.
Financial constraints
„„
Diabetes care, including treatment of its asso­
ciated complications, often requires expensive
healthcare resources such as hospitalization
charges, laboratory tests and drugs (Figure 1) . A
study from India showed that the total annual
cost of diabetes care varied from 1230 bil­
lion Indian Rupees (INR; $25.5 billion) to
34 Diabetes Manage. (2013) 3(1)
INR1837.3 billion ($38.0 billion) in the year
2010 [31] . Presence of complications further
increases the cost of treatment; for example, a
recent study reported that the cost of diabetes
care for a patient with foot ulcers was more than
four times higher (INR19,020; US$409) than
that for a patient without foot ulcers (INR 4493;
US$97) [32] .
The patient bears the excessive cost and the
economic loss due to lost workdays or lost eco­
nomic opportunity. In general, the absence of a
significant or credible social security system in
India requires the patient to depend on family
support. This means that if the breadwinner of
the family suffers a chronic illness, it would have
a significant effect on the whole family. It may
force other nonworking members to start work,
often prematurely at lower wages, cut short chil­
dren’s education with long-term financial conse­
quence for them and the family [33] . In the study
by Tharkar et al., it was observed that more than
60% of the low-income group had to borrow
or mortgage property for their diabetes treat­
ment costs and approximately 70–80% of the
high income group spent most of their personal
savings on treatment [31] . Hence, it can be said
that the financial burden borne by people with
diabetes and their families depends on their eco­
nomic status and the social insurance policies of
the country.
In the poorest countries, people with diabetes
and their families bear almost the whole cost
of medical care. In India, a situation prevails
in which individuals with limited financial
resources continue to spend a major proportion
of their income on diabetes management [34] .
This situation is a major financial burden to
people in India, owing to poor economic condi­
tions, unlike in developed nations. Moreover,
the presence of associated complications further
increases their financial burden. A study from
south India reported the increasing expenditure
by patients with diabetic complications in both
rural and urban settings (Figure 2) [34] . The total
annual cost to treat diabetic patients in India
(including direct and indirect expenses) was esti­
mated to be $420 per capita. If that per capita
expenditure were to remain constant, the total
estimated cost of treating the disease would
reach $30 billion by 2025 [103] .
The concept of medical reimbursement in the
form of insurance policies is still not put into its
full use by the majority of developing nations.
In an analysis using data from 35 low- and
future science group

middle-income countries, such as Kenya,
Vietnam, Bangladesh, Mali, Ethiopia, Pakistan
and India, included in the World Health Survey
[104] , Smith-Spangler et al. reported that health
insurance had a meager role in reducing the
medical expenses of diabetic individuals [35] .
Studies in India reported that only 6.4% of
the urban low-income group received medical
reimbursement, whereas this was 21.3% in the
high-income group [34] . This implies that even in
urban settings, the concepts of health insurance
and mediclaim policies seem better understood
and are only utilized by the high-income group.
Health resources in India and other devel­
oping countries are very limited with only 5%
of gross domestic product (GDP), being spent
on healthcare [105] . The majority of healthcare
expenditure was private (4% of GDP) with
only 0.9% of GDP spent on public healthcare.
Therefore, careful planning based on health
economic assessments is necessary in order to
maximize the use of funds for the treatment and
prevention of diabetes [33] .
Social barriers
„„
Apart from financial constraints, there are some
sociocultural barriers that can be a stumbling
block for the proper management of diabetes.
In some developing countries, youngsters who
have been newly diagnosed with diabetes some­
times do not reveal their condition and most
probably do not take insulin or medications due
to the social stigma attached to the condition
when finding spouses, in addition to the exces­
sive cost spent and the chance of being excluded
from certain jobs or turned down for insurance
or mortgage products [101] . Diabetes care in such
cases becomes difficult and physicians may face
a challenge in advising these patients appropri­
ately. Moreover, although the majority of dia­
betic cases in India are diagnosed and managed
by general practitioners, including cardiologists,
neurologists and nephrologists, there is a lack
of regular monitoring and patient education for
these patients. This situation implies that general
physicians need to understand and update their
knowledge on diabetes education and prevention
aspects, and monitoring of patients to prevent
complications.
„„Economic disparities in the healthcare
system
NCDs such as diabetes have not received
enough medical attention as communicable
future science group
Problems associated with diabetes care in India  Special Report
Disposables (3%)
Other drugs (11%)
Hospitalization (35%)
Antidiabetic drugs (17%)
Monitoring and
laboratory tests (22%) Doctor visit (12%)
Figure 1. Distribution of direct costs in diabetes care.
Data taken from [33].
diseases such as tuberculosis and AIDS in India.
Therefore, the allocation of financial resources
towards diabetes or cardiovascular diseases is
much less when compared with those allocated
to infectious diseases [101] .
In India, there is a wide disparity in the
healthcare facilities available in rural and urban
areas due to the nonuniformity of the health­
care system. Healthcare delivery is shared by
the institutions run by the state (where medical
care is free or offered at subsidized rates), pri­
vate institutions (where patients have to pay for
services) and a large number of medical practi­
tioners. People do not have any restrictions in
utilizing any of the available medical facilities
and they can access any level of care depend­
ing on their economic feasibility, proximity and
knowledge about the facility. Individuals who
can afford it are able to attend the private centers
for their diabetes care [36] . Nevertheless, there
is a considerable variation in the quality and
cost of care from place to place, depending on
the available resources, the physician’s skill and
interest in diabetes, and the patients’ capability
to spend. The hospital services are provided by
government hospitals, including district hospi­
tals and medical college hospitals. Treatment
in government hospitals is provided free or at
a nominal charge depending on the person’s
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Special Report  Viswanathan & Rao
30,000
Urban
Rural
25,000
Expenditure incurred (INR)
20,000
15,000
10,000
5000
0 present in India, which leads to delay in diagno­
0 1 2 sis and improper management of blood glucose
Complications (n)
Figure 2. Expenditure incurred by urban and rural subjects in relation to the
number of complications.
INR: Indian Rupees.
Reproduced with permission from [34].
income; however, due to scant and limited
resources and poor infrastructure, government
care focuses mainly on acute pressing illnesses,
rather than diabetes. Therefore, on the whole,
the quality of diabetes care is low.
The scenario in the private sector is quite
different, where treatment is based mainly on
monetary resources. Those seeking private med­
ical care have to pay for everything themselves
as there is limited or no reimbursements, and
here too, the infrastructure for chronic care is
limited. In the past few decades, several high-
tech corporate medical facilities have arisen
in India, which aim to provide sophisticated
healthcare, although only affluent people can
have access to it. This increases the expectations
of the poorer sections of society, who anticipate
the same services from government institutions
[36] . Although private healthcare facilities are
sought after, it is likely that many patients may
cross over to public healthcare facilities due to
financial burdens.
In the rural areas, health facilities that are
based on primary health centers and subcent­
ers need more attention, because these are not
well appreciated due to inadequacy of facilities
(lack of staff, equipment, laboratory facilities
36 Diabetes Manage. (2013) 3(1)
and essential drugs). Some nongovernmental
organizations offer free healthcare facilities for
the low economic classes, but again these are less
utilized due to lack of awareness, poor education
and occupational problems.
Hence, long-term prognosis of diabetes is
affected due to lack of adequate facilities (in
the government sector) and capacity to pay
(in the private sector). When uniformly good
quality care is accessible to all, the disease out­
come is at least not predetermined by individu­
als’ socio­economic standing. The prevailing
poverty, ignorance, illiteracy and poor health
consciousness further adds to the problem [33] .
Adherence to recommended guidelines
„„
Suboptimal knowledge of or improper adher­
ence to the recommended guidelines is an issue
levels, resulting in an increase in other compli­
cations. In the IMPROVE Control India study,
it was observed that although most physicians
agreed that HbA1c testing is crucial, it was only
prescribed in 79% of the patients, whereas fast­
ing and postprandial glucose tests were admin­
istered for 97 and 96% of patients, respectively.
Many physicians felt that standardization of gly­
cated hemoglobin (HbA1c) in laboratories is not
reliable and, therefore, preferred the fasting and
postprandial glucose measurements [30] . Another
recent study by Tharkar et al. observed that most
of the recommended clinical guidelines for dia­
betes care, such as performing HbA1c tests,
advising about self-monitoring of glucose and
diabetes education were not being adhered to
in most of the government healthcare centers
in India [37] . Even among the private institu­
tions, only 31.7% of specialty clinics prescribed
HbA1c tests. Professional advice and counseling
regarding healthy lifestyle, diet modification and
physical activity methods was given only at spe­
cialized diabetes centers, while such advice was
almost absent in the government hospitals [37] .
Nonadherence to recommended guidelines may
lead to poor glycemic control, which can directly
raise the risk of complications and increase the
cost burden.
Need to strengthen the existing
„„
healthcare infrastructure
Despite the steep growth in the Indian econ­
omy, there has been a lag in the growth of
India’s healthcare infrastructure, which is quite
future science group

inadequate to meet today’s healthcare demands.
While India has several centers of excellence in
healthcare delivery, these facilities are limited
in their ability to drive healthcare standards
because of the poor condition of the infrastruc­
ture in the vast majority of the country. Of the
15,393 hospitals in India in 2002, roughly two-
thirds were public. After years of under-funding,
most public health facilities provide only basic
care. With a few exceptions, public health facili­
ties are inefficient, inadequately managed and
staffed, and have poorly maintained medical
equipment. The number of public health facili­
ties is also inadequate. For example, India needs
74,150 community health centers per million
people, but has less than half that number. In
addition, at least 11 Indian states do not have
laboratories for testing drugs, and more than
half of existing laboratories are not properly
equipped or staffed. The principal responsibil­
ity for public health funding lies with the state
governments, which provide approximately 80%
of public funding. The central government con­
tributes another 15%, mostly through national
health programs [103] . Hence, there is an urgent
need to improve the existing medical infrastruc­
ture in order to strengthen the healthcare needs
of the people.
Prevention of diabetes
One of the fundamental aspects in the preven­
tion of diabetes and its complications is impart­
ing appropriate education to the community and
at-risk population. An effective educational pro­
gram insisting on physical activity, consuming a
healthy diet, avoiding alcohol and smoking, and
leading a stress-free life could be very effective in
reducing the burden of diabetes. Every diabetic
clinic and hospital must ensure that a patient
receives the proper diabetes education at every
visit. Implementation of all these strategies may
not be practical in a country such as India, which
is slowly emerging out of poverty and still strug­
gling with problems such as unemployment. In
this situation, healthcare organizations have a
significant role in promoting diabetes education
and management through community-based
campaigns at the community level.
Diabetes education programs
„„
The Prevention, Awareness, Counselling and
Evaluation (PACE) diabetes project was a suc­
cessful venture undertaken to increase awareness
about diabetes, its risk factors and complications
future science group
Problems associated with diabetes care in India  Special Report
among the general population in Chennai city
of Tamil Nadu, India [38] . Diabetes education
was imparted to the population through public
education, media campaigns, general practitioner
training and community-based ‘real life’ preven­
tion programs. One of the major outcomes of the
PACE project was that there was approximately
a 6% increase in the number of people reporting
that they knew about diabetes. There were also
significant increases in the awareness levels of
risk factors, such as family history of diabetes,
obesity, stress and hypertension, among the pop­
ulation of Chennai. Increases in the knowledge
levels of diabetic complications such as nephrop­
athy, retino­pathy and foot problems were also
observed in this study. In addition, nearly 46%
of the people realized that diabetes could be
prevented after attending the PACE program [38] .
Another recent study was carried out to assess
whether a short messaging service through
mobile phones could motivate patients to adhere
to treatment prescriptions, which included
enhanced physical activity, diet modifications
and the use of drugs [39] . It was observed that
the majority of patients with access to a mobile
phone and knowledge of the English language
preferred to receive messages on all aspects of
diabetes care. The messages consisted of instruc­
tions on diet, physical activity, reminders for
following drug prescriptions and healthy liv­
ing habits. Patients who received the messages
showed significant reductions in their glyce­
mic levels compared with the control group of
patients who received the same diabetes care
with the exception of the message service [39] .
Studies on awareness and education for dia­
betic foot complications have shown promising
results in preventing and reducing the burden
of foot ulceration and amputations. A research
study from India had shown the beneficial
effects of foot care education, which involved
simple foot care management advice to patients,
such as daily examination of feet, how to per­
form a pedicure and usage of proper/therapeu­
tic footwear. Foot care education was effective
in healing foot ulcers in more than 80% of the
patients. A higher number of patients (26%)
who did not adhere to foot care advice devel­
oped newer foot problems and required surgical
procedures, compared with those who followed
the advice (14%) [40] . Moreover, those who regu­
larly wore the prescribed therapeutic footwear
showed significant reductions in reoccurrence of
foot ulcers [41] . Approximately 60% of patients’
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Special Report  Viswanathan & Rao
ulcers healed and they remained ulcer-free over
a 34‑month period of observation. Recurrence of
healed ulcers occurred in only a sixth of patients
and amputation was required in 1% of subjects
[41] . These studies demonstrate that it is possible
to reduce the burden of foot problems by educat­
ing patients on foot care and using appropriate
footwear.
Nevertheless, large-scale programs have to
be effectively implemented to cover the whole
nation, for which both the public and private
sectors need to work together. The National
Rural Health Mission has launched a new pilot
National Programme for Prevention and Control
of Diabetes, Cardiovascular Disease and Stroke,
which could offer opportunities for improving
care for diabetes and other NCDs through ser­
vice provision at the primary and secondary lev­
els of care [42] . Guidelines for the management
of diabetes in the Indian context have also been
developed through a joint consultation by the
ICMR and WHO [43] .
Diabetes education, awareness and improving
motivation for self-care improves care, reduces
complications and may reduce the overall eco­
nomic costs of diabetes. Lifestyle modifica­
tions such as weight control, increased physical
exercise and smoking cessation are potentially
beneficial in preventing diabetes mellitus [44] .
Prevention of diabetes must essentially aim at
targeting two main groups of population: the
high-risk group that includes individuals with
a family history of diabetes who carry a genetic
susceptibility, individuals with impaired glu­
cose tolerance, aging individuals, sedentary
individuals and the obese; and the general
population, for whom strategies to lower the
mean risk level of diabetes can be implemented
by advising them to engage in regular aerobic
physical activity, improve their diet and reduce
obesity. Several studies of community-based
NCD prevention projects have attempted to
prevent the onset of diabetes through lifestyle
modifications, a reduction in obesity or through
pharmaco­logical means. Such projects have also
clearly demonstrated a significant reduction of
risk factors by following a healthy lifestyle [106]
and maintaining normal body weight (BMI:
18.5–24.9 kg/m2) [2] , which could in turn bring
a huge benefit to the community.
Conclusion & future perspective
The overwhelmingly increasing number of
people with diabetes in a country such as India
38 Diabetes Manage. (2013) 3(1)
poses several challenges that have to be critically
met with for the proper management and care
of diabetes. Problems such as lack of appropri­
ate infrastructure and health personnel, poor
updating of knowledge about diabetes among
general practitioners, poor access to diabetes
drugs and healthcare facilities, economic dis­
parities in the healthcare system, and the socio­
economic burden on the patient are the main
obstacles in diabetes care.
Effective management of people with diabetes
offers only part of the solution for the problem
of diabetes, which means that other aspects of
care important from the perspective of diabetes
control may be difficult to provide within the
health system itself. Aspects related to diet and
the amount of physical activity undertaken will
be influenced by an interplay of various sectoral
policies and forces. In India, several rural areas
are still facing the problem of undernutrition
and are unable to access better food products.
Dietary restriction advice for diabetic patients in
such areas becomes difficult, which means that
national or state policies for food procurement,
pricing and marketing have to be implemented
for a sustained availability of inexpensive and
accessible dietary substitutes in the market.
Population-based strategies for health promo­
tion and risk reduction, along with surveillance
of trends in disease and risk factors, are equally
important components in any public health
approach for diabetes control.
The health system in India, as in other coun­
tries, is traditionally designed to focus on acute
illnesses and maternal and child health prob­
lems. This means that there is still a lack of
appropriate infrastructure and healthcare per­
sonnel to meet the raising demands of NCDs,
which require the availability of trained cli­
nicians, investigational facilities and drugs.
Recently, owing to several community-based
research studies, the importance of primary pre­
vention through promotion of healthy lifestyles
and risk reduction has been recognized as the
most cost-effective intervention in resource-poor
settings. Therefore, the health system in India
has to strengthen the standard of diabetes care
at all levels, along with nationally accepted man­
agement protocols and regulatory framework,
which can help in tackling this challenge.
In conclusion, strong and effective preven­
tive measures addressing all these problems
have to be framed by the government, other
stakeholders and policy makers, and ensure that
future science group
 Problems associated with diabetes care in India  Special Report

they are implemented and followed up success­
fully, in order to tackle the problems involved
in diabetes care in India. In addition, health­
care professionals have a big role to play in this
regard, as they must always maintain up-to-
date knowledge required for the diagnosis and
treatment of diabetes, and they should stress
the need for effective education on all aspects
of diabetes care for the patients as well as the
general population.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.

13 Ramachandran A, Snehalatha C, Kapur A Epidemiology Study (CURES-45). Diabetes

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